2.0 Analysis 2.1 Introduction This analysis deals with the automated system of the JADE STAR, crew training, the laboratory tests conducted on the ruptured retaining pin and the reasons for the vessel yawing quickly to port. 2.2 Automated System of the JADE STAR All the systems on board the JADE STAR are monitored by computer. When a system malfunctions, alarms are triggered, and the essential systems are automatically replaced by backup systems. With the information obtained from the computer, the operator can diagnose the problem and determine a remedial course of action. When the alarms went off, the propeller pitch was reduced to zero, and no attempt was made to control the vessel with the rudder until the master ordered the helm hard-a-starboard. Lack of familiarity with the vessel's system prevented the personnel from pinpointing the cause of the problem and determining an effective course of action. If the problem had been diagnosed correctly, the engineer could have shut down the No.2 generator, and the stand-by generator would have come on-line automatically after seven seconds, thus quickly restoring power. 2.3 Training on the Automated System Different tasks and duties require different methods of training. Training, when properly designed and delivered, yields dividends in terms of efficiency and safety. On-the-job training can be very effective as it allows for a smooth transition between training and work because the conditions are virtually identical. Personnel trained solely on the job can be well prepared to perform their duties under normal circumstances. On-the-job training unaccompanied by formal instruction or personal study, however, provides poor preparation for unusual situations that require a thorough understanding of the design and operating parameters of the system. In the case of the grounding of the JADE STAR, the engine-room and bridge personnel had to deal with an unusual situation for which they were not trained. An inadequate knowledge of the system rather than a software design defect exacerbated the problem. More adequate training might have helped the crew members diagnose the problem properly, find the solution and restore power more quickly. 2.4 Interpretation of the Printout The printout shows that, by 0634EDT, there was a problem on the electrical system caused by a voltage fluctuation. In less than a minute, three variations in voltage caused an overload of the controls of the steering gear and triggered a series of alarms. This temporary overload would not normally have impaired the operation of the steering gear. The voltage fluctuations caused the breaker for non-essential equipment to trip twice. When this breaker tripped, the bridge personnel assumed that there was a complete power failure. The OOW reduced the propeller pitch to zero and did not try to keep the vessel in the channel. 2.5 Tests of the Ruptured Metal Pin The ruptured metal retaining pin from the cover of the fuel filter mounted on the No.2 generator of the JADE STAR was tested by the TSB Engineering Laboratory. The tests revealed that the fracture surfaces showed a uniform appearance with no evidence of precracking or progressive failure of any kind. The fracture surfaces showed only microvoid coalescence structures consistent with the overload failure of a nominally ductile material. The filter cover came loose while the generator was under full load, thus causing a voltage fluctuation on the electrical system. 2.6 Anchorage According to the evidence, the starboard anchor was dropped when the JADE STAR was south of the centre line of the channel and yawing to port. The anchor chain probably passed under the vessel which was travelling at some 13knots and accelerated the rotary motion to port. The bridge personnel of the BAMIA confirmed that the JADE STAR had been observed to yaw quickly to port and to run aground on the southern edge of the channel after the JADE STAR informed the BAMIA that she was experiencing a mechanical failure and asked to keep clear of her. 2.7 Sound Level of the Alarms It was reported that the sound of the alarms was so loud as to interfere with portable radio communication between the wheel-house and the bow of the vessel. The audible alarms could have been deactivated by the navigation personnel. 3.0 Conclusions 3.1 Findings The electrical system on the JADE STAR was not being operated as it was designed to operate at sea. A ruptured retaining pin for the cover in one of the fuel filters of the No.2 generator caused a voltage fluctuation. The bridge and engine-room personnel had to deal with an unusual situation for which they were not trained. The propeller pitch was reduced to zero, and no attempt was made by the bridge personnel to control the vessel with the rudder until the master ordered the helm hard-a-starboard. A more thorough knowledge of the system and of the parameters of the software could have helped the crew members make a more accurate diagnosis of the problem and restore power more quickly. The manuals for the automated system were on board, but they and some other system manuals were written in German, a language not understood by the shipboard personnel. 3.2 Causes The rupture of a cover retaining pin in one of the fuel filters of the No.2 generator caused an electrical problem. Believing a black-out to have occurred, the officer of the watch set the propeller pitch to zero; he did not attempt steering, and the vessel sheered out of the channel and grounded. The crew of the JADE STAR lacked experience with the on-board automated system and was therefore unable to react quickly and effectively enough to recognize and rectify the problem. 4.0 Safety Action 4.1 Action Taken 4.1.1 New Directive Immediately following the occurrence, the operator issued a directive to the JADE STAR and her two sister ships to operate on the shaft generator. 4.1.2 Engineering Laboratory Report Following the occurrence, the TSB conducted an analysis of the broken stud from a fuel filter mounted on the No.2 generator. The results of this analysis indicated an overload failure. The Engineering Laboratory report was forwarded to the owners/operators for their information. 4.1.3 Training on the Automated System The importance of adequate crew training commensurate with the highly automated machinery and control systems installed on the JADE STAR and her two sister vessels was discussed at a meeting between TSB staff and representatives of the manufacturer, the charterer, the shipping agent, and the Canadian Coast Guard (CCG). In 1996, a TSB Marine Safety Advisory was forwarded to the operating company with respect to the effectiveness of the operations and automated system manuals. It was also suggested that the operating company assess the need for additional crew training in the fleet's automated system.